Birth Mother Declaration Concerning the Birth Father

Instructions

This is a legal document and needs to be filled out completely. Leave a space blank ONLY if you do not know the information requested.

1.

My name is*

FirstLast

I declare that I am the mother of the child named (or may be named)

This child...*

was born

is expected to be born

...on this birth/due date...*

...in this city/state.*

CityState

2.

The child was conceived in...*

State

I have lived in the following states during my pregnancy.*

Click the plus sign to add a new row.

3.

Do you know the biological father?*

Yes

No

The biological father's name is...*

His address is

Street AddressCityStateZIP Code

His date of birth is...

His phone number is...

His social security number is...

I don't know his date of birth, but his approximate age is...

4.

I am...*

Not married to the biological father and have never been married to him.

Married to the biological father.

5

I notified the biological father that I was pregnant.*

Yes

No

Approximate Date

That he is the biological father or may be the biological father.*

Yes

No

Approximate Date

That I intended to consent to adoption or to relinquish the child in Utah.*

Yes

No

Approximate Date

That I intended to consent to adoption under Utah law.*

Yes

No

Approximate Date

That I intended to relinquish the child to a Utah adoption agency.*

Yes

No

Approximate Date

That I intended to relinquish the child to a Utah adoptive family.*

Yes

No

Approximate Date

That I was traveling to or planning to reside in Utah.*

Yes

No

Approximate Date

6.

I contacted the birth father when I was in Utah.*

Yes

No

Approximate Date

I have....

Not contacted the birth father while I was in Utah

Not been in Utah at all

7.

The biological father (if the child is already born)

has never lived with the child

lived with the child for the length of time stated below

Number of months the biological father lived with the child.

8.

The biological father...

did not give me any money and did not offer to pay any money for my expenses during my pregnancy or the child’s birth

offered me money to pay for my expenses during my pregnancy or the child’s birth but I refused to accept anything.

gave me the amount stated below for my expenses during my pregnancy or the child's birth

The dollar amount of support given to be by the biological father.

9.

The biological father...*

never offered to pay for pregnancy or child expenses.

offered to pay for pregnancy or child expenses.

Did he follow though? How? How much?

10.

I am not aware of any legal action taken by the biological father to establish paternity of the child, either in Utah or in any other state*

Yes. I'm unaware of any legal action.

No. He has taken legal action.

State he has taken legal action

State

Describe the legal action he has taken

11.

I have been involved in a domestic violence matter with the biological father.*

Yes

No

If you can, describe any of the following: date(s), place(s), description, reported, charges, court involvement

Your Email Address*

Email Preferences

We understand that, in some circumstances, it might not be a good idea to have proof of your communication with us in your inbox. So, please let us know your preference below.

No. Please DO NOT email me a confirmation.

Yes. Please send an email confirmation for my records.

I object to the requirements of Utah Code Ann. § 78B-6-110.5 on the ground that requiring me to disclose detailed information about a sexual partner violates my right to privacy, deprives me of my liberty interest in keeping the intimate details of my life confidential, and denies me equal protection under the law by treating me differently than women who do not place a child for adoption, including women who choose to have an abortion. I believe I have a constitutional right not to disclose this information as well as a statutory right pursuant to Utah Code Ann. § 78B-6-102(7). I provide the following information under protest without waiving my objection of any rights I may have, including any cause of action I may have under federal law.
I understand the agency, if any, the adoptive parents, and the court will rely on this document. I declare under criminal penalty of the State of Utah that the foregoing is true and correct.

Objection Signature (optional)

Signature

Date Signed*

Type Your Name*

FirstLast

I, the undersigned, declare that I am not under the influence of any drugs, alcohol or medication that may influence my reasoning or judgment and sign this document by my own free will and choice.